Standard for Psychotherapy, 2023

Standard for Psychotherapy

This Standard applies to occupational therapists who perform psychotherapeutic techniques, including psychotherapy as a controlled act under the Regulated Health Professions Act, 1991 (RHPA). The Occupational Therapy Act, 1991includes regulations that apply to occupational therapists when performing the controlled act of psychotherapy (see Appendix 1).

The definition of the controlled act of psychotherapy references a client’s “serious disorder” (“of thought, cognition, mood, emotional regulation, perception or memory”) that may seriously impair their “judgement, insight, behaviour, communication or social functioning” (Occupational Therapy Act, s. 3.1 [1]). Because psychotherapeutic services that occupational therapists provide carry with them a risk of harm even when the client’s disorder may not be “serious,” to ensure the greatest public protection, these Standards apply to occupational therapists performing all types of psychotherapeutic techniques, including the controlled act of psychotherapy. Refer to the supporting document “When the Standard for Psychotherapy Applies: Occupational Therapy in Mental Health” in Appendix 2 for more information.

The College recognizes that clients’ disorders and levels of impairment can fluctuate during the provision of services. In response, occupational therapists providing psychotherapy are to have the competency to adapt to clients’ evolving needs.

This Standard does not apply when occupational therapists are using approaches that are not psychotherapeutic, such as health teaching, supportive listening, and coaching. Again, even if the client’s current level of impairment may not be considered “serious” or one that may “seriously impair” their judgement or other areas mentioned above, this Standard applies when the occupational therapist is using any psychotherapeutic technique.

Occupational therapists are expected to:

1. Obtain and maintain competence

Performing psychotherapy is not an entry-level practice competency. It is an intentional and defined approach, and it is not recommended to be an occasional practice. Occupational therapists must obtain and maintain competence in each psychotherapy technique they intend to use.

Occupational therapists are to obtain psychotherapy training that has these components: instructional (is instructor led, not self-taught), theoretical (is based on psychotherapeutic theories), and practical (involves supervision). Pairing supervision with instruction and theoretical training allows for the practical application of theory to practice.

Instructional and theoretical educational requirements

1.1

Select training that is appropriate for the occupational therapist’s learning needs. At the beginning, it is expected that the instructional and theoretical components of training provide foundational understanding of the psychoeducational modalities. Afterwards, it may be appropriate to use other methods to continue competence (for example, workshops, professional networks, literature reviews, and continuous quality improvement initiatives). Factors that may contribute to the selection of education options include client needs, evidence-informed approaches, the scope of services, previous training and experience, comprehensiveness, and the relevance of the training.

Practical (supervision) requirements

Supervision is an intentional arrangement where an experienced and qualified provider of psychotherapy assists the occupational therapist being supervised in their professional growth. This structured process allows the occupational therapist to develop foundational competence and the ability to provide safe, ethical, and efficient services. Supervision can be tailored to the occupational therapist’s individual needs. Methods of supervision may include one-to-one meetings or supervision in a small group setting. The requirements for supervision are outlined as follows:

1.2

Participate in a period of formal, practical psychotherapy supervision that includes the following:

Quantity: Supervision is a formal arrangement and a long-term commitment. It is to occur at regular intervals for the duration of the supervisory period, with a recommended minimum of 50 hours of supervision over at least the first two years of psychotherapy practice. This may extend longer for an occupational therapist who is not performing psychotherapy full time. Some training institutions may require specific supervision beyond this minimum.
Quality: Supervisors must be experienced, competent to provide supervision, and eligible to perform the controlled act of psychotherapy. Supervisors can be occupational therapists or other health professionals. The supervisor must be a member of the College of Nurses of Ontario, the College of Occupational Therapists of Ontario, the College of Physicians and Surgeons of Ontario, the College of Psychologists of Ontario, the College of Registered Psychotherapists of Ontario, or the Ontario College of Social Workers and Social Service Workers. Supervision needs to align with the occupational therapist’s experience and specific psychotherapeutic approach. Occupational therapists who provide supervision do not take accountability for clients. The occupational therapist being supervised is responsible for the client services they provide.

1.3

Have a supervisory agreement which should include:

Administrative details (for example, start and end dates and frequency of meetings)
Responsibilities of the supervisor and the occupational therapist being supervised
Confirmation of accountability for client services
Processes to follow in the case of emergency

1.4

Maintain supervisory or meeting notes that do not contain personal information or personal health information. This requirement applies to both the supervisor and the occupational therapist being supervised, and it applies for at least the duration of the supervisory agreement. Notes that contain clients’ information must be retained in accordance with the Standard for Record Keeping. Meeting notes can include:

Meeting dates
Summary of any ethical or professional issues addressed
Any direction, recommendations, feedback, or evaluation provided
Record of payments made for supervision

1.5

During the consent dialogue with clients, inform them of any supervisory arrangements.

1.6

Never participate in supervisory arrangements solely for billing purposes. Financial records should clearly identify who provided the direct services to clients.

1.7

If requested by the College, provide verifiable documentation of the completion of both an educational program and a required period of psychotherapy supervision.

After the required period of formal supervision, the occupational therapist may choose to continue with this supervision or move to a consultation arrangement in their psychotherapy practice. Consultation enables an occupational therapist to continue their professional growth. Consultation is with an experienced and qualified regulated psychotherapy professional to meet, discuss and review client care and share expertise. Individual or group consultation methods are acceptable. The individuals involved in this arrangement can determine the method of documentation for the consultation process.

2. Practise safely

The Standard for Psychotherapy applies to occupational therapists providing psychotherapy across all sectors and settings. Because settings vary, it is important for occupational therapists to consider the cultural origins of the psychotherapy techniques and modalities being used and use them in culturally sensitive ways. Through the therapeutic relationship, occupational therapists develop an understanding of the client’s unique perspectives and personal experiences.

2.1

Before services begin, review the referral information to confirm that the client needs psychotherapy services. The occupational therapist must determine whether they have the competence (knowledge, skills, and judgement) to deliver the appropriate psychotherapy services, including the controlled act of psychotherapy.

2.2

Ensure that clients are aware that they are taking part in psychotherapy services. Obtain ongoing consent.

2.3

Understand and follow the laws and regulations governing the practice of psychotherapy.

2.4

Perform psychotherapy within the occupational therapist’s role and the scope of occupational therapy practice. Make referrals to other qualified providers as needed.

2.5

Identify, minimize, and manage the risks associated with performing psychotherapy.

2.6

Establish and maintain professional boundaries as outlined in the Standard for Professional Boundaries and the Prevention of Sexual Abuse.

2.7

Hold a general certificate of registration to practise psychotherapy unless permission from the Registrar has been obtained (temporary certificates may be issued to occupational therapists who are registered in another jurisdiction and are providing in-person services in Ontario on a temporary basis).

3. Do not delegate or assign psychotherapy services to others

3.1

Use clinical judgement to determine when or if it is appropriate for students or re-entry candidates (those returning to the profession after a prolonged absence) to be included in psychotherapy practice. While students or re-entry candidates may be able to independently provide general mental health interventions, they can observe psychotherapy or employ psychotherapy techniques with clients only when their supervisor is present.

3.2

Never assign any part of psychotherapy practice or delegate psychotherapy to anyone else, including occupational therapy assistants.

4. Use title appropriately

Section 33.1 of the RHPA permits occupational therapists to use the title “psychotherapist” only if they identify themselves as members of the College by using the title “occupational therapist” as well. This applies to both oral and written communications.

4.1

Determine, based on their competence, when it is appropriate to add the title “psychotherapist.”

4.2

Use acceptable versions of title, such as:

First name Last name, OT Reg. (Ont.), Psychotherapist
First name Last name, Occupational Therapist, Psychotherapist
First name Last name, Occupational Therapist, practising psychotherapy.

Appendix 1: Occupational Therapy Act, 1991

The definition of the controlled act of psychotherapy is set out in section 3.1 (1) of the Occupational Therapy Act, 1991:

A member is authorized, subject to the terms, conditions and limitations imposed on his or her certificate of registration, to treat, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning.

Occupational Therapy Act, 1991: Ontario Regulation 474/19: Controlled Acts

Psychotherapy technique

1. (1) For the purposes of subsection 3.1 (2) of the Act, a member holding a general practising certificate of registration may treat, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning if the member meets the standards of practice set out in subsection (3) of this section.

(2) For the purposes of subsection 3.1 (2) of the Act, a member holding a temporary certificate of registration who has the approval of the Registrar may treat, by means of psychotherapy technique delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning if the member meets the standards of practice set out in subsection (3) of this section.

(3) It is a standard of practice of the profession that a member referred to in subsection (1) or (2) who performs the controlled act described in those subsections must comply with the following:

1. Either have formal psychotherapy training that includes instructional, theoretical, and practical components or else have a combination of training and experience that in the opinion of the College is equivalent to such training.

2. Maintain competence by engaging in ongoing psychotherapy-based learning activities.

3. Have the knowledge, skill and judgment to perform the controlled act safely, effectively and ethically.

4. Have the knowledge, skill and judgement to determine whether the individual’s condition warrants performance of the controlled act.

5. Determine that the individual’s condition warrants performance of the controlled act, having considered,

the known risks and benefits to the individual of performing the controlled act,
the predictability of the outcome of performing the controlled act,
the safeguards and resources available in the circumstances to safely manage the outcome of performing the controlled act, and
other relevant factors specific to the situation.

No delegation

2. A member shall not delegate the performance of the controlled act authorized by subsection 3.1 (1) of the Act.

Appendix 2: When the Standard for Psychotherapy Applies: Occupational Therapy in Mental Health

This table provides a general distinction between psychotherapy and other foundational mental health services that occupational therapists provide. The purpose is to help clarify when the Standard for Psychotherapy applies to practice. While not every scenario is represented below, the factors to consider (left column) can guide occupational therapists with other clinical situations they encounter.

	Psychotherapy (Psychotherapy Standard Applies)	Occupational Therapy Mental Health Services (Psychotherapy Standard Does Not Apply)
Referral and Consent	The referral specifies that the client is to receive psychotherapy services. If not explicitly stated, the occupational therapist determines, based on the clinical information, whether psychotherapy intervention is indicated. Within the consent dialogue outlined in the Standard for Consent, the occupational therapist informs the client that the services involve the use of psychotherapy.	The referral involves enabling the client’s overall occupational performance, including, and sometimes primarily, supporting the client’s mental health. Consent follows the protocols in the Standard for Consent.
Competence	Providing psychotherapy services is not an entry-level skill. Additional education and supervision are required.	Providing mental health services requires general occupational therapy knowledge, skill, and judgement. Additional training may be required for competence in providing specific approaches.
Description	Occupational therapy services that use psychotherapy are often used to treat mental illness and promote wellness and occupational participation. Psychotherapy can be described as a relational process between a client and the therapist. Specific psychotherapeutic approaches are applied collaboratively to the assessment and intervention of a client’s thoughts, emotions, and/or behaviours. The purpose is to promote occupational participation for better day-to-day functioning in activities and roles meaningful to the client. Psychotherapy is done within the scope of occupational therapy practice. The controlled act of psychotherapy is defined in legislation and can be found in this Standard. See Understanding When Psychotherapy Is a Controlled Act for additional details on the controlled act.	Occupational therapy services are aimed at supporting a client’s occupational possibilities and participation as they relate to overall mental health and well-being. This is done within the scope of occupational therapy practice.
Approaches	Some of the many approaches or therapies used in psychotherapy are listed below. This is not an exhaustive list. Occupational therapists may refer to the College of Registered Psychotherapists of Ontario for a more complete list. Given the integral value of the therapeutic relationship, occupational therapists should also have a background in safely and effectively sharing their own experiences with clients to help clients understand their own situations. ▪ Cognitive and behavioural ▪ Experiential and humanistic ▪ Psychodynamic ▪ Somatic ▪ Systemic and collaborative	Some of the approaches that are used by occupational therapists to support mental health include:Case management ▪ Coaching ▪ Encouragement and advice giving ▪ Health and symptom monitoring ▪ Psychoeducation ▪ Skills teaching ▪ Supportive listening
Techniques	While psychotherapeutic techniques are too numerous to provide a comprehensive list, examples of common techniques include ▪ Acceptance and Commitment Therapy ▪ Cognitive Behavioural Therapy ▪ Dialectical Behavioural Therapy ▪ Exposure Therapy	While techniques are too numerous to provide a comprehensive list, examples include: ▪ Activity analysis ▪ Goal-setting methods ▪ Motivational interviewing ▪ Wellness recovery action planning
Practice Scenarios	Scenario 1. An occupational therapist works as part of an intensive psychotherapy treatment program for adolescents with eating disorders. The occupational therapist co-facilitates an intensive, long-term treatment group using Dialectical Behavioural Therapy and Emotion-Focused Therapy. Scenario 2. An occupational therapist has a private practice offering psychotherapy to individuals diagnosed with an anxiety and/or depression disorder. These disorders seriously impact occupational participation in many domains. The occupational therapist uses various trauma-informed and psychotherapeutic techniques, including Cognitive Behavioural Therapy and Interpersonal Psychotherapy as well as incorporating art and visual expression in treatment.	Scenario 1. An occupational therapist who does not have training or competence in psychotherapy is working with a university-aged client who is struggling in school. Although the client has some underlying anxiety, they are managing a part-time job and are passing school with some accommodations. In addition to the primary goal of helping the client to organize their schoolwork, the occupational therapist teaches SMART goal-setting techniques, uses motivational interviewing strategies, and provides education about time use, daily scheduling, and prioritization. Scenario 2. An occupational therapist works as part of a community mental health team and provides case management to clients with complex, long-term, and serious psychiatric illness. Supportive listening and encouragement, teaching de-escalation techniques, safety planning, and service referral are commonly used interventions to help clients to reach their occupational goals.

References

Occupational Therapy Act, 1991, Statutes of Ontario (1991, c. 33). Retrieved from the Government of Ontario website: https://www.ontario.ca/laws/statute/91o33

Ontario Regulation 474/19, Controlled Acts. (2019). Retrieved from the Government of Ontario website: https://www.ontario.ca/laws/regulation/190474

Regulated Health Professions Act, 1991, Statutes of Ontario (1991, c. 18). Retrieved from the Government of Ontario website: https://www.ontario.ca/laws/statute/91r18

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